New Jersey and Texas introduce breast cancer screening measures. Tennessee holds hearings on out-of-network billing and modifying scope of physician assistants (PAs) and advanced practice registered nurses (APRNs). Legislatures advance additional measures modifying scope of practice for PAs and APRNs.
Breast Cancer Screening
In New Jersey, A 5477 was referred to the Assembly Health Committee. It would require healthcare providers to order bilateral ultrasounds concurrently when ordering mammograms and would require carriers to cover the concurrent mammograms and ultrasounds.
In Texas, HB 2909 was introduced and referred to the Insurance Committee. The bill would mandate that carriers that cover screening mammograms cover diagnostic imaging.
Diagnostic imaging means “using a mammography, ultrasound, or magnetic resonance imaging” examination designed to evaluate:
- A subjective or objective abnormality detected by a physician in a breast;
- An abnormality seen by a physician on a screening mammogram;
- An abnormality previously identified by a physician as probably benign in a breast for which follow-up imaging is recommended by a physician; or
- An individual with a personal history of breast cancer or dense breast tissue.
The companion bill in the Senate, SB 1065 was referred to the Business and Commerce Committee.
Also in Texas, HB 3423 was introduced and referred to the Insurance Committee. The bill would require carriers to cover supplemental two- or three-dimensional breast ultrasound imaging as part of an annual screening covered under the plan if the provider treating the enrollee or screening the enrollee for breast cancer finds that the enrollee has dense breast tissue. Coverage would be subject to the same coinsurance factors as for other radiological examinations under the plan.
Out-of-Network Billing
In Tennessee, SB 1 and HB 2 will be heard before the Senate Commerce and Labor Committee and House Insurance Subcommittee, respectively. Both bills would require the state insurance commissioner to establish an independent dispute resolution process to resolve disputes regarding bills for out-of-network emergency services. The commissioner would promulgate rules establishing standards for the independent dispute resolution process, including a process for certifying and selecting independent dispute resolution entities.
In determining the appropriate amount to pay for a healthcare service, an independent dispute resolution entity would not consider:
(1) Any benchmarking database that includes Medicare or Medicaid reimbursement rates; or
(2) Medicare or Medicaid reimbursement rates.
An out-of-network facility-based physician, healthcare facility, or health carrier may submit a dispute regarding a fee or payment for emergency services for review to an independent dispute resolution entity. The independent dispute resolution entity would decide on a reasonable fee for the services rendered within 30 days of receipt of the dispute for review.
When determining a reasonable fee for the services rendered, the independent dispute resolution entity would select either the health carrier payment or the out-of-network facility-based physician's fee.
If an independent dispute resolution entity determines, based on the health carrier's payment and the out-of-network facility-based physician's fee, that a settlement between the health carrier and out-of-network facility-based physician is reasonably likely, or that both the health carrier's payment and the out-of-network facility-based physician's fee represent unreasonable extremes, then the independent dispute resolution entity may direct both parties to attempt a good faith negotiation for settlement. In that case, the health carrier and out-of-network physician may be granted up to 10 business days for negotiation, which runs concurrently with the thirty-day period for dispute resolution. An out-of-network facility-based physician may request, and the independent dispute resolution entity may permit, that claims of a physician involving the same health carrier be aggregated and submitted for simultaneous review by an independent dispute resolution entity when the specific reason for nonpayment of the claims aggregated involve a dispute regarding a common substantive question of fact or law.
If a balance bill is received by an enrollee for elective services who does not assign benefits, or who is uninsured, then the enrollee may submit a dispute regarding the balance bill for review to an independent dispute resolution entity that shall determine a reasonable fee for the services rendered.
For disputes involving an enrollee:
- When the independent dispute resolution entity determines the health carrier's payment is reasonable, the out-of-network facility-based physician or healthcare facility would pay for arbitration; and if the entity determines the out-of-network facility-based physician's or healthcare facility's fee is reasonable, the carrier would pay for arbitration.
- When a good faith negotiation directed by the independent dispute resolution entity results in a settlement between the carrier and the out-of-network facility-based physician or healthcare facility, the carrier and the out-of-network facility-based physician or healthcare facility shall evenly divide and share the prorated cost of the dispute resolution.
Scope of Practice
Arkansas’ Gov. Hutchinson signed HB 1258 into law. It will grant full independent practice authority to nurse practitioners (NPs) that complete 10,400 hours of practice under a collaborative practice agreement with a physician. NPs will be permitted to prescribe therapeutic devices appropriate to the NP’s area of practice.
In Delaware, HB 33 passed both chambers. The bill seeks to change the practice agreement between a physician assistant and physician from supervising to a collaborating agreement. PAs would also be permitted to order therapeutic orders or procedures.
In North Carolina, SB 345 passed the first reading in the Senate and was referred to the Committee on Rules and Operations. The bill seeks to permit PAs to practice without supervision if:
- The physician assistant practices in “team-based” settings; and
- The physician assistant has more than 4,000 hours of practice experience as a licensed PA and more than 1,000 hours of practice within the specific medical specialty of practice under physician supervision.
PAs would be permitted to plan and initiate a therapeutic regimen that includes ordering and prescribing non-pharmacological interventions, including durable medical equipment. However, PAs would be prohibited from performing final interpretations of diagnostic imaging which would include: all plain film radiographs, CT, MRI, nuclear medicine, PET, mammography, and ultrasound goods and services.
In Tennessee, HB 1080 will be heard before the Health Subcommittee. It would seek to permit PAs to order, perform and interpret diagnostic studies and therapeutic procedures.
Also in Tennessee, SB 176 will be heard before the Senate Commerce and Labor Committee. The bill seeks to permit APRNs to plan and initiate a therapeutic regimen that includes ordering and prescribing non-pharmacological interventions, including durable medical equipment, medical devices, and diagnostic and supportive services.
In Texas, HB 2029 was introduced and referred to the Public Health Committee. The measure seeks to permit APRNs to order, perform and interpret diagnostic tests.
The Texas Radiological Society will be closely monitoring this proposed measure.
To stay abreast of state legislative developments relevant to radiology, view our policy map.